Incontinence after prostate therapy (IPT) is caused by damage to the striated muscle and nerve fibers of the voluntary (striated) urethral sphincter
The term “incontinence after prostate treatment” is used in this guideline over the familiar term “post-prostatectomy incontinence” because it is more inclusive and covers males who have incontinence after undergoing radical prostatectomy (RP), radiotherapy (RT) or BPH-surgery
Commonly accepted definition of urinary continence: not requiring a pad or protective device to stay dry (pad-free)
Factors associated with increased risk of incontinence after RP (5):
Older age
Larger prostate size
Shorter membranous urethral length
Lack of preservation of bilateral neurovascular bundle at time of RP
No surgical maneuvers, other than preservation of bilateral neurovascular bundle, results in improved continence recovery. Men receiving bilateral neurovascular bundle preservation were 26% more likely to be continent at 6 months compared to men who did not
Prior pelvic radiation
Radiation is a significant risk factor for IPT in patients undergoing RP or TURP.
These patients should be informed that they may require an artificial urinary sphincter (AUS).
Surgical approach: open RP has similar rates of urinary incontinence as robot-assisted RP
BMI may impact IPT in the short-term; however, not considered to impact risk at 1-year after RP
Natural history
Continence after RP improves with time, and most men achieve continence within 12 months of surgery
Most men undergoing RP are not continent (pad-free) at the time of catheter removal and should be informed that continence is not immediate.
Majority of patients will reach their maximum improvement by 12 months with minimal to no improvement afterwards.
90% of patients will achieve continence at 6 months after robotic-assisted laparoscopic prostatectomy and only an additional 4% of patients will gain continence afterwards.
Conservative management with regular follow-up during the first year after surgery is recommended to assess patient progress
In addition to SUI, patients can also develop sexual arousal incontinence and climacturia following RP
Pelvic floor muscle exercises (PFME)/Pelvic floor muscle training (PFMT)
PFME is self-guided whereas PFMT is practitioner guided; both are training programs specific to the pelvic muscles
Thought to support muscle strength and enhance blood flow to the sphincter to promote healing
Prior to radical prostatectomy: may reduce the risk of IPT
The benefit of starting pre-operative PMFT is not consistent
Exercises are easier to learn in the pre-operative period due to post-operative muscle inhibition, sensory changes, urinary incontinence, and surgical pain
Immediate post-operative period: should be offered
Improves time to continence (thus improving QoL) but not overall continence at 12 months
Treatment for SUI (caused by sphincteric insufficiency) vs. urgency incontinence (caused by bladder dysfunction) are different.
In cases of mixed incontinence, determine which component is more prevalent and bothersome (stress or activity related versus urgency related)
Increases in abdominal pressure such as that caused by straining, walking, cough, and exercise are suggestive of SUI
The sudden compelling desire to void that is difficult to defer and results in leakage indicates urgency incontinence.
Presence of incontinence while asleep as well as nocturia are also important to note, because this may indicate urgency urinary incontinence or severe SUI.
Progression or resolution of incontinence over time, exacerbating factors
Severity of incontinence (i.e. volume lost over time)
Can be determined by history, or more objectively, by pad testing
In the case of sphincteric insufficiency, some treatments (e.g., male slings), clearly have inferior results in severe incontinence.
Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the AUA Overactive Bladder Guidelines
If there is no improvement at 6 months despite conservative therapy and the patient has bothersome IPT, (i.e. patient does not want to wait until 12 month time point) surgery may be considered for early treatment
While almost all patients have reached their maximum improvement by 12 months, most patients with severe SUI will show no significant improvement after 6 months and may be candidates for early intervention
Otherwise, treatment should be offered to patients with persistent bothersome SUI at 12 months.
Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months
SUI should be confirmed by history, physical exam, or ancillary testing
If there is any doubt as to whether the patient has SUI; all reasonable measures to demonstrate SUI on physical exam, with or without provocative testing such as bending, shifting position, or rising from seated to standing position, should be taken
Cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery
Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for IPT
Urodynamics (UDS) may be performed.
UDS are not required before surgical intervention for IPT unless the clinician is in doubt of the diagnosis or it is felt that patient counseling will be affected.
During UDS, it is important that the catheter be removed and stress testing repeated in patients with suspected SUI who do not demonstrate stress incontinence with a catheter in place
Up to 35% of males with post-prostatectomy SUI will not demonstrate SUI with a catheter in place. This may be due to some scarring at the site of the anastomosis. In such cases, even a small catheter can occlude the urethra and prevent stress leakage.
It is not known if poor bladder compliance and an uncorrected storage pressure are absolute contraindications to SUI surgery in IPT patients (***Campbell's lists this as contraindication***). However, these patients should be carefully followed to avoid upper tract decompensation.
Poor efficacy in comparison to an AUS in patients with severe incontinence.
Risks (generally low complication rate):
Urinary retention
Typically resolves within 1 week
Pelvic and perineal pain and paresthesia
Typically resolves within 12 weeks
Erosion or infection
Both are exceedingly rare.
If a male sling is thought to be infected or documented to be eroded on cystoscopy, the management is similar to management of an infected or eroded AUS (see below)
Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy
Complication rates are higher
Urethral reconstruction
Urethral strictures of the anterior urethra and urethral stenosis of the posterior urethra can arise after RP, RT, or treatment for IPT. Urethral reconstructive surgery is often used to treat narrowing in the urethra.
Male slings will not be effective given post-surgical changes related to most types of urethral reconstruction in the posterior and anterior urethra
Complications rates are higher
Depending on the technique employed (urethra transecting or not) the blood supply to the urethra may be diminished and potentially decrease the life span of an AUS.
Vesicourethral anastomotic stenosis or bladder neck contracture
Decreased success rates when undergoing male slings
If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed
Persistent leakage
Cuff erosion
Can be due to unrecognized urethral injury at the time of initial surgery or more likely due to subsequent instrumentation of the urethra including catheterization.
Management:
AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal
AUS should not be re-implanted until at least 3 months
Infection
Device infection occurs in <1-5% of cases
Diagnosis and Evaluation
History and Physical Exam
Presents with (4):
Pain at the site of the AUS
Fever
Scrotal warmth or erythema
Skin changes
Management:
Urgent AUS explantation
AUS should not be reimplanted until at least 3 months to allow the infection to clear and inflammation to subside.
Mechanical failure
Decreased efficacy over time and reoperations are common
The current version consists of a hydraulic system composed of 3 separate parts:
A urethral cuff of varying sizes
A pressure regulating balloon reservoir with three available pressure profiles
A control pump
The device will fail if any of the 3 parts, the tubing, or connections suffer a micro-perforation with loss of fluid
The rate of device failure increases with time, with failure rates of
≈24% at 5 years
≈ 50% at 10 years
AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to (3):
Can be considered in appropriately motivated and counseled patients who are unable to obtain adequate long-term quality of life
If bladder preservation is feasible, conversion to a Mitrofanoff (e.g. Appendix, Monti), incontinent ileovesicostomy, or suprapubic tube with bladder neck closure may confer an improved QoL.
In the event of the “hostile” bladder, cystectomy in combination with either an ileal conduit or continent catheterizable pouch would best manage incontinence while protecting the upper tracts.
In a patient with bothersome climacturia, treatment may be offered.
As with post-prostatectomy SUI, for those with sexual arousal incontinence or climacturia, conservative management (emptying the bladder prior to sex, use of condoms to catch the urine, and PFME) should be the initial treatment
Imipramine, a tricyclic antidepressant, has been used, but this medication is generally contraindicated in men age > 65 due to the risk of somnolence, falling down, and changes in cognition.
Both the AUS and the trans-obturator male sling, when implanted for SUI, are associated with high rates of improvement in climacturia